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  • Review Article
  • Published:

Management of hypertension in chronic kidney disease

Nature Reviews Nephrology volume 11, pages 555–563 (2015)Cite this article

Subjects

Key Points

  • Elevated blood pressure can occur as a result of, and be a potent risk factor for, chronic kidney disease (CKD) progression

  • CKD is associated with dysregulation of various blood pressure control systems, including the ability to excrete the daily sodium load, sympathetic activation, renin–angiotensin system activity, and endothelial function

  • Although controversial, the Joint National Committee recommends target blood pressure levels <140/90 mmHg in US patients with CKD until 70 years of age

  • Most guidelines for hypertension treatment in CKD recommend administration of an agent that blocks the renin–angiotensin system, with follow-up testing of kidney function and serum potassium concentrations

  • Home and ambulatory blood pressure monitoring can improve the assessment of overall blood pressure control in patients with CKD, as compared to office measurements alone

  • Device-based methods for blood pressure reduction, such as renal denervation and baroreceptor activation therapy, suggest safety in CKD; unequivocal efficacy remains to be shown in sham-controlled studies

Abstract

Hypertension is a common comorbidity in patients with impaired kidney function. The kidney exerts a marked degree of control over blood pressure through various mechanisms, such as by regulating sodium balance and hormone secretion through the activity of the renin–angiotensin system. The kidney is susceptible to injury, and if already damaged can be at risk of further loss of function as a consequence of elevated blood pressure. Once elevated blood pressure is identified, a combination of sensible lifestyle measures, such as sodium restriction and weight loss, with pharmacological intervention to reduce blood pressure will usually achieve blood pressure goals. In this Review, we outline the importance of blood pressure control for patients with chronic kidney disease (CKD), the mechanisms that affect blood pressure control, and the basis for non-drug and drug therapies. We further discuss the rationale for <140 mmHg systolic and <90 mmHg diastolic targets for blood pressure in patients with CKD, with consideration for tighter targets in the setting of proteinuria.

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Figure 1: Integration of the processes and pathways that regulate blood pressure.

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Authors and Affiliations

  1. University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, 19104, PA, USA

    Raymond R. Townsend

  2. Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street Southwest, Rochester, 55905, MN, USA

    Sandra J. Taler

Authors
  1. Raymond R. Townsend
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  2. Sandra J. Taler
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Both authors researched data for the article, provided substantial contributions to discussion of its content, wrote the article and undertook review and/or editing of the manuscript before submission.

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Correspondence to Raymond R. Townsend.

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The authors declare no competing financial interests.

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Townsend, R., Taler, S. Management of hypertension in chronic kidney disease. Nat Rev Nephrol 11, 555–563 (2015). https://doi.org/10.1038/nrneph.2015.114

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